Systems and methods for a medical clip applier

ABSTRACT

Certain aspects relate to systems and techniques for articulating medical instruments. In one aspect, the instrument includes a wrist having at least one degree of freedom of movement, and an end effector coupled to the wrist. The end effector can include a cartridge for delivering a plurality of clips to tissue. The wrist may include one or more cables capable of moving an actuator with one degree of freedom of movement within the end effector to advance one or more clips through the end effector.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No. 16/903,154, filed Jun. 16, 2020, which claims the benefit of U.S. Provisional Application No. 62/867,452, filed Jun. 27, 2019, which are hereby incorporated by reference in their entirety.

TECHNICAL FIELD

The systems and methods disclosed herein are directed to medical instruments, and more particularly to clip appliers.

BACKGROUND

Medical clips can be used in a variety of different medical procedures, including, for example, laparoscopic procedures in which the medical clips may be used to ligate and/or seal tissue to stop bleeding. The use of clips can reliably engage tissue and be retained and secured in place. The use of clips to ligate tissue can advantageous as they can be faster than the use of sutures to ligate tissue.

SUMMARY

The systems, methods and devices of this disclosure each have several innovative aspects, no single one of which is solely responsible for the desirable attributes disclosed herein.

In a first aspect, a robotically controlled surgical instrument includes a wrist extending from the distal end of the elongate shaft, the wrist providing at least one degree of freedom of movement, and an end effector extending from the wrist and moveable with the wrist, the end effector comprising a cartridge for delivering a plurality of clips in succession without reloading.

The robotically controlled surgical instrument may further include one or more of the following features in any combination: (a) wherein the plurality of clips includes at least four clips; (b) wherein the plurality of clips are nested with each other within the cartridge; (c) wherein a length of the plurality of clips is at least 50% less than if the plurality of clips were each laid end to end; (d) wherein first open ends of the plurality of clips are positioned within the first track; (e) wherein the shaft is coupled to a robotic arm; (f) wherein each of the plurality of clips includes a first arm with a distal end and a second arm with a distal end, the first and second arms connected together at their respective proximal ends; (g) wherein the cartridge includes a first track and a second track, and wherein the distal end of each of the first arms is positioned within the first track and the distal end of each of the second arms is positioned within the second track to hold each of the plurality of clips in an open position; (h) wherein when each of the clips are expelled from the cartridge, the first and second arm of each of the clips move towards each other to a closed position; (i) wherein in the closed position the distal end of the first arm is intermeshed with the distal end of the second arm; (j) wherein each of the plurality of clips are configured to be stored in the cartridge in the open position and be closed onto tissue in the closed position, wherein the distal end of the first arm and the distal end of the second arm are separated from each other in the open position, wherein the distal end of the first arm and the distal end of the second arm are intermeshed with each other; (k) wherein the distal end of the first arm includes a tab; (l) wherein the distal end of the second arm includes a loop that is larger than the tab of the first arm; (m) wherein the tab of the first arm includes a loop that is smaller than the loop of the second arm; (n) wherein the first and second arms connect together at their respective proximal ends by a loop; (o) wherein the first and second arms connect together at their respective proximal ends by a plurality of loops; and/or (p) wherein the elongate shaft is capable of movement in one degree of freedom.

In another aspect, a surgical instrument includes an elongate shaft extending between a proximal end and a distal end, a wrist extending from the distal end of the elongate shaft, and an end effector extending from the wrist. The wrist can include one or more cables capable of moving an actuator with one degree of freedom of movement within the end effector to advance one or more clips through the end effector. The one or more clips can be capable of being both delivered and automatically clipped by the one degree of freedom movement of the actuator.

The surgical instrument may further include one or more of the following features in any combination: (a) wherein the one or more clips are received in a cartridge; (b) wherein the one or more clips move along a track within the cartridge; (c) wherein the track is configured to engage with a distal end of each of the one or more clips to hold the each of the one or more clips in an open position prior to delivery; (d) wherein the actuator advances the one or more clips along the track with the cartridge; and/or (e) wherein the elongate shaft is capable of movement in one degree of freedom.

In another aspect, a surgical instrument for securing tissue includes a cartridge including one or more clips, the one or more clips each includes a first arm including a first distal portion and a second arm including a second distal portion. The one or more clips can include a first configuration in an open position and a second configuration in a closed position. The first distal portion can be capable of intermeshing with the second distal portion when the clip is in the closed position. The first arm may include a single strut and the second arm may include a pair of struts, the single strut of the first arm capable of moving between pair of struts of the second arm.

In yet another aspect, a surgical clip configured to close on tissue includes a first arm including a first strut, and a second arm including a second strut and a third strut. A distal end of the first arm can intermesh with a distal end of the second arm. A proximal end of the first arm and a proximal end of the second arm are joined to form a vertex, the vertex forming a torsion spring.

The surgical clip configured to close on tissue may further include one or more of the following features in any combination: (a) wherein the distal end of the first strut forms a loop; (b) wherein the distal ends of the second strut and third strut form a loop that is larger than the loop of the first strut; (c) wherein the larger loop of the second strut and the third strut receives the smaller loop of the first strut when the clip is in a closed position; (d) wherein the first strut is received between the second strut and the third strut when the clip is in a closed position; and/or (e) wherein the torsion spring comprises one or more loops.

BRIEF DESCRIPTION OF THE DRAWINGS

The disclosed aspects will hereinafter be described in conjunction with the appended drawings, provided to illustrate and not to limit the disclosed aspects, wherein like designations denote like elements.

FIG. 1 illustrates an embodiment of a cart-based robotic system arranged for diagnostic and/or therapeutic bronchoscopy.

FIG. 2 depicts further aspects of the robotic system of FIG. 1 .

FIG. 3 illustrates an embodiment of the robotic system of FIG. 1 arranged for ureteroscopy.

FIG. 4 illustrates an embodiment of the robotic system of FIG. 1 arranged for a vascular procedure.

FIG. 5 illustrates an embodiment of a table-based robotic system arranged for a bronchoscopic procedure.

FIG. 6 provides an alternative view of the robotic system of FIG. 5 .

FIG. 7 illustrates an example system configured to stow robotic arm(s).

FIG. 8 illustrates an embodiment of a table-based robotic system configured for a ureteroscopic procedure.

FIG. 9 illustrates an embodiment of a table-based robotic system configured for a laparoscopic procedure.

FIG. 10 illustrates an embodiment of the table-based robotic system of FIGS. 5-9 with pitch or tilt adjustment.

FIG. 11 provides a detailed illustration of the interface between the table and the column of the table-based robotic system of FIGS. 5-10 .

FIG. 12 illustrates an alternative embodiment of a table-based robotic system.

FIG. 13 illustrates an end view of the table-based robotic system of FIG. 12 .

FIG. 14 illustrates an end view of a table-based robotic system with robotic arms attached thereto.

FIG. 15 illustrates an exemplary instrument driver.

FIG. 16 illustrates an exemplary medical instrument with a paired instrument driver.

FIG. 17 illustrates an alternative design for an instrument driver and instrument where the axes of the drive units are parallel to the axis of the elongated shaft of the instrument.

FIG. 18 illustrates an instrument having an instrument-based insertion architecture.

FIG. 19 illustrates an exemplary controller.

FIG. 20 depicts a block diagram illustrating a localization system that estimates a location of one or more elements of the robotic systems of FIGS. 1-10 , such as the location of the instrument of FIGS. 16-18 , in accordance to an example embodiment.

FIG. 21 illustrates an example embodiment of a medical instrument in accordance with aspects of this disclosure.

FIG. 22A illustrates an example embodiment of a surgical clip in an open position.

FIG. 22B illustrate the surgical clip of FIG. 22A in the closed position.

FIG. 22C illustrates a side view of the surgical clip of FIGS. 22A and 22B in an open position.

FIG. 22D illustrates a side view of the surgical clips of FIGS. 22A-22C in a closed position.

FIG. 22E illustrates a side view of the surgical clips of FIGS. 22A-22D in a closed position.

FIG. 23 illustrates the surgical clip closed on a vessel.

FIG. 24A illustrates another example embodiment of a surgical clip in an open position.

FIG. 24B illustrates the surgical clip of FIG. 24A in a closed position.

FIG. 25A illustrates a top perspective view of a clip applier or cartridge.

FIG. 25B illustrates a bottom perspective view of the clip applier or cartridge of FIG. 25A.

FIG. 25C illustrates a front perspective view of the clip applier or cartridge of FIGS. 25A-25B.

FIG. 26 illustrates a cartridge with the first and bottom plates removed.

FIGS. 27A and 27B illustrate side views of the cartridge with that includes tracks for engagement with the clips.

FIGS. 28A and 28B illustrate the cartridge with the outer housing removed.

DETAILED DESCRIPTION

1. Overview.

Aspects of the present disclosure may be integrated into a robotically enabled medical system capable of performing a variety of medical procedures, including both minimally invasive, such as laparoscopy, and non-invasive, such as endoscopy, procedures. Among endoscopic procedures, the system may be capable of performing bronchoscopy, ureteroscopy, gastroscopy, etc.

In addition to performing the breadth of procedures, the system may provide additional benefits, such as enhanced imaging and guidance to assist the physician. Additionally, the system may provide the physician with the ability to perform the procedure from an ergonomic position without the need for awkward arm motions and positions. Still further, the system may provide the physician with the ability to perform the procedure with improved ease of use such that one or more of the instruments of the system can be controlled by a single user.

Various embodiments will be described below in conjunction with the drawings for purposes of illustration. It should be appreciated that many other implementations of the disclosed concepts are possible, and various advantages can be achieved with the disclosed implementations. Headings are included herein for reference and to aid in locating various sections. These headings are not intended to limit the scope of the concepts described with respect thereto. Such concepts may have applicability throughout the entire specification.

A. Robotic System—Cart.

The robotically enabled medical system may be configured in a variety of ways depending on the particular procedure. FIG. 1 illustrates an embodiment of a cart-based robotically enabled system 10 arranged for a diagnostic and/or therapeutic bronchoscopy. During a bronchoscopy, the system 10 may comprise a cart 11 having one or more robotic arms 12 to deliver a medical instrument, such as a steerable endoscope 13, which may be a procedure-specific bronchoscope for bronchoscopy, to a natural orifice access point (i.e., the mouth of the patient positioned on a table in the present example) to deliver diagnostic and/or therapeutic tools. As shown, the cart 11 may be positioned proximate to the patient's upper torso in order to provide access to the access point. Similarly, the robotic arms 12 may be actuated to position the bronchoscope relative to the access point. The arrangement in FIG. 1 may also be utilized when performing a gastro-intestinal (GI) procedure with a gastroscope, a specialized endoscope for GI procedures. FIG. 2 depicts an example embodiment of the cart in greater detail.

With continued reference to FIG. 1 , once the cart 11 is properly positioned, the robotic arms 12 may insert the steerable endoscope 13 into the patient robotically, manually, or a combination thereof. As shown, the steerable endoscope 13 may comprise at least two telescoping parts, such as an inner leader portion and an outer sheath portion, each portion coupled to a separate instrument driver from the set of instrument drivers 28, each instrument driver coupled to the distal end of an individual robotic arm. This linear arrangement of the instrument drivers 28, which facilitates coaxially aligning the leader portion with the sheath portion, creates a “virtual rail” 29 that may be repositioned in space by manipulating the one or more robotic arms 12 into different angles and/or positions. The virtual rails described herein are depicted in the Figures using dashed lines, and accordingly the dashed lines do not depict any physical structure of the system. Translation of the instrument drivers 28 along the virtual rail 29 telescopes the inner leader portion relative to the outer sheath portion or advances or retracts the endoscope 13 from the patient. The angle of the virtual rail 29 may be adjusted, translated, and pivoted based on clinical application or physician preference. For example, in bronchoscopy, the angle and position of the virtual rail 29 as shown represents a compromise between providing physician access to the endoscope 13 while minimizing friction that results from bending the endoscope 13 into the patient's mouth.

The endoscope 13 may be directed down the patient's trachea and lungs after insertion using precise commands from the robotic system until reaching the target destination or operative site. In order to enhance navigation through the patient's lung network and/or reach the desired target, the endoscope 13 may be manipulated to telescopically extend the inner leader portion from the outer sheath portion to obtain enhanced articulation and greater bend radius. The use of separate instrument drivers 28 also allows the leader portion and sheath portion to be driven independently of each other.

For example, the endoscope 13 may be directed to deliver a biopsy needle to a target, such as, for example, a lesion or nodule within the lungs of a patient. The needle may be deployed down a working channel that runs the length of the endoscope to obtain a tissue sample to be analyzed by a pathologist. Depending on the pathology results, additional tools may be deployed down the working channel of the endoscope for additional biopsies. After identifying a nodule to be malignant, the endoscope 13 may endoscopically deliver tools to resect the potentially cancerous tissue. In some instances, diagnostic and therapeutic treatments can be delivered in separate procedures. In those circumstances, the endoscope 13 may also be used to deliver a fiducial to “mark” the location of the target nodule as well. In other instances, diagnostic and therapeutic treatments may be delivered during the same procedure.

The system 10 may also include a movable tower 30, which may be connected via support cables to the cart 11 to provide support for controls, electronics, fluidics, optics, sensors, and/or power to the cart 11. Placing such functionality in the tower 30 allows for a smaller form factor cart 11 that may be more easily adjusted and/or re-positioned by an operating physician and his/her staff. Additionally, the division of functionality between the cart/table and the support tower 30 reduces operating room clutter and facilitates improving clinical workflow. While the cart 11 may be positioned close to the patient, the tower 30 may be stowed in a remote location to stay out of the way during a procedure.

In support of the robotic systems described above, the tower 30 may include component(s) of a computer-based control system that stores computer program instructions, for example, within a non-transitory computer-readable storage medium such as a persistent magnetic storage drive, solid state drive, etc. The execution of those instructions, whether the execution occurs in the tower 30 or the cart 11, may control the entire system or sub-system(s) thereof. For example, when executed by a processor of the computer system, the instructions may cause the components of the robotics system to actuate the relevant carriages and arm mounts, actuate the robotics arms, and control the medical instruments. For example, in response to receiving the control signal, the motors in the joints of the robotics arms may position the arms into a certain posture.

The tower 30 may also include a pump, flow meter, valve control, and/or fluid access in order to provide controlled irrigation and aspiration capabilities to the system that may be deployed through the endoscope 13. These components may also be controlled using the computer system of the tower 30. In some embodiments, irrigation and aspiration capabilities may be delivered directly to the endoscope 13 through separate cable(s).

The tower 30 may include a voltage and surge protector designed to provide filtered and protected electrical power to the cart 11, thereby avoiding placement of a power transformer and other auxiliary power components in the cart 11, resulting in a smaller, more moveable cart 11.

The tower 30 may also include support equipment for the sensors deployed throughout the robotic system 10. For example, the tower 30 may include optoelectronics equipment for detecting, receiving, and processing data received from the optical sensors or cameras throughout the robotic system 10. In combination with the control system, such optoelectronics equipment may be used to generate real-time images for display in any number of consoles deployed throughout the system, including in the tower 30. Similarly, the tower 30 may also include an electronic subsystem for receiving and processing signals received from deployed electromagnetic (EM) sensors. The tower 30 may also be used to house and position an EM field generator for detection by EM sensors in or on the medical instrument.

The tower 30 may also include a console 31 in addition to other consoles available in the rest of the system, e.g., console mounted on top of the cart. The console 31 may include a user interface and a display screen, such as a touchscreen, for the physician operator. Consoles in the system 10 are generally designed to provide both robotic controls as well as preoperative and real-time information of the procedure, such as navigational and localization information of the endoscope 13. When the console 31 is not the only console available to the physician, it may be used by a second operator, such as a nurse, to monitor the health or vitals of the patient and the operation of the system 10, as well as to provide procedure-specific data, such as navigational and localization information. In other embodiments, the console 30 is housed in a body that is separate from the tower 30.

The tower 30 may be coupled to the cart 11 and endoscope 13 through one or more cables or connections (not shown). In some embodiments, the support functionality from the tower 30 may be provided through a single cable to the cart 11, simplifying and de-cluttering the operating room. In other embodiments, specific functionality may be coupled in separate cabling and connections. For example, while power may be provided through a single power cable to the cart 11, the support for controls, optics, fluidics, and/or navigation may be provided through a separate cable.

FIG. 2 provides a detailed illustration of an embodiment of the cart 11 from the cart-based robotically enabled system shown in FIG. 1 . The cart 11 generally includes an elongated support structure 14 (often referred to as a “column”), a cart base 15, and a console 16 at the top of the column 14. The column 14 may include one or more carriages, such as a carriage 17 (alternatively “arm support”) for supporting the deployment of one or more robotic arms 12 (three shown in FIG. 2 ). The carriage 17 may include individually configurable arm mounts that rotate along a perpendicular axis to adjust the base of the robotic arms 12 for better positioning relative to the patient. The carriage 17 also includes a carriage interface 19 that allows the carriage 17 to vertically translate along the column 14.

The carriage interface 19 is connected to the column 14 through slots, such as slot 20, that are positioned on opposite sides of the column 14 to guide the vertical translation of the carriage 17. The slot 20 contains a vertical translation interface to position and hold the carriage 17 at various vertical heights relative to the cart base 15. Vertical translation of the carriage 17 allows the cart 11 to adjust the reach of the robotic arms 12 to meet a variety of table heights, patient sizes, and physician preferences. Similarly, the individually configurable arm mounts on the carriage 17 allow the robotic arm base 21 of the robotic arms 12 to be angled in a variety of configurations.

In some embodiments, the slot 20 may be supplemented with slot covers that are flush and parallel to the slot surface to prevent dirt and fluid ingress into the internal chambers of the column 14 and the vertical translation interface as the carriage 17 vertically translates. The slot covers may be deployed through pairs of spring spools positioned near the vertical top and bottom of the slot 20. The covers are coiled within the spools until deployed to extend and retract from their coiled state as the carriage 17 vertically translates up and down. The spring-loading of the spools provides force to retract the cover into a spool when the carriage 17 translates towards the spool, while also maintaining a tight seal when the carriage 17 translates away from the spool. The covers may be connected to the carriage 17 using, for example, brackets in the carriage interface 19 to ensure proper extension and retraction of the cover as the carriage 17 translates.

The column 14 may internally comprise mechanisms, such as gears and motors, that are designed to use a vertically aligned lead screw to translate the carriage 17 in a mechanized fashion in response to control signals generated in response to user inputs, e.g., inputs from the console 16.

The robotic arms 12 may generally comprise robotic arm bases 21 and end effectors 22, separated by a series of linkages 23 that are connected by a series of joints 24, each joint comprising an independent actuator, each actuator comprising an independently controllable motor. Each independently controllable joint represents an independent degree of freedom available to the robotic arm 12. Each of the robotic arms 12 may have seven joints, and thus provide seven degrees of freedom. A multitude of joints result in a multitude of degrees of freedom, allowing for “redundant” degrees of freedom. Having redundant degrees of freedom allows the robotic arms 12 to position their respective end effectors 22 at a specific position, orientation, and trajectory in space using different linkage positions and joint angles. This allows for the system to position and direct a medical instrument from a desired point in space while allowing the physician to move the arm joints into a clinically advantageous position away from the patient to create greater access, while avoiding arm collisions.

The cart base 15 balances the weight of the column 14, carriage 17, and robotic arms 12 over the floor. Accordingly, the cart base 15 houses heavier components, such as electronics, motors, power supply, as well as components that either enable movement and/or immobilize the cart 11. For example, the cart base 15 includes rollable wheel-shaped casters 25 that allow for the cart 11 to easily move around the room prior to a procedure. After reaching the appropriate position, the casters 25 may be immobilized using wheel locks to hold the cart 11 in place during the procedure.

Positioned at the vertical end of the column 14, the console 16 allows for both a user interface for receiving user input and a display screen (or a dual-purpose device such as, for example, a touchscreen 26) to provide the physician user with both preoperative and intraoperative data. Potential preoperative data on the touchscreen 26 may include preoperative plans, navigation and mapping data derived from preoperative computerized tomography (CT) scans, and/or notes from preoperative patient interviews. Intraoperative data on display may include optical information provided from the tool, sensor and coordinate information from sensors, as well as vital patient statistics, such as respiration, heart rate, and/or pulse. The console 16 may be positioned and tilted to allow a physician to access the console 16 from the side of the column 14 opposite the carriage 17. From this position, the physician may view the console 16, robotic arms 12, and patient while operating the console 16 from behind the cart 11. As shown, the console 16 also includes a handle 27 to assist with maneuvering and stabilizing the cart 11.

FIG. 3 illustrates an embodiment of a robotically enabled system 10 arranged for ureteroscopy. In a ureteroscopic procedure, the cart 11 may be positioned to deliver a ureteroscope 32, a procedure-specific endoscope designed to traverse a patient's urethra and ureter, to the lower abdominal area of the patient. In a ureteroscopy, it may be desirable for the ureteroscope 32 to be directly aligned with the patient's urethra to reduce friction and forces on the sensitive anatomy in the area. As shown, the cart 11 may be aligned at the foot of the table to allow the robotic arms 12 to position the ureteroscope 32 for direct linear access to the patient's urethra. From the foot of the table, the robotic arms 12 may insert the ureteroscope 32 along the virtual rail 33 directly into the patient's lower abdomen through the urethra.

After insertion into the urethra, using similar control techniques as in bronchoscopy, the ureteroscope 32 may be navigated into the bladder, ureters, and/or kidneys for diagnostic and/or therapeutic applications. For example, the ureteroscope 32 may be directed into the ureter and kidneys to break up kidney stone build up using a laser or ultrasonic lithotripsy device deployed down the working channel of the ureteroscope 32. After lithotripsy is complete, the resulting stone fragments may be removed using baskets deployed down the ureteroscope 32.

FIG. 4 illustrates an embodiment of a robotically enabled system 10 similarly arranged for a vascular procedure. In a vascular procedure, the system 10 may be configured such that the cart 11 may deliver a medical instrument 34, such as a steerable catheter, to an access point in the femoral artery in the patient's leg. The femoral artery presents both a larger diameter for navigation as well as a relatively less circuitous and tortuous path to the patient's heart, which simplifies navigation. As in a ureteroscopic procedure, the cart 11 may be positioned towards the patient's legs and lower abdomen to allow the robotic arms 12 to provide a virtual rail 35 with direct linear access to the femoral artery access point in the patient's thigh/hip region. After insertion into the artery, the medical instrument 34 may be directed and inserted by translating the instrument drivers 28. Alternatively, the cart may be positioned around the patient's upper abdomen in order to reach alternative vascular access points, such as, for example, the carotid and brachial arteries near the shoulder and wrist.

B. Robotic System—Table.

Embodiments of the robotically enabled medical system may also incorporate the patient's table. Incorporation of the table reduces the amount of capital equipment within the operating room by removing the cart, which allows greater access to the patient. FIG. 5 illustrates an embodiment of such a robotically enabled system arranged for a bronchoscopic procedure. System 36 includes a support structure or column 37 for supporting platform 38 (shown as a “table” or “bed”) over the floor. Much like in the cart-based systems, the end effectors of the robotic arms 39 of the system 36 comprise instrument drivers 42 that are designed to manipulate an elongated medical instrument, such as a bronchoscope 40 in FIG. 5 , through or along a virtual rail 41 formed from the linear alignment of the instrument drivers 42. In practice, a C-arm for providing fluoroscopic imaging may be positioned over the patient's upper abdominal area by placing the emitter and detector around the table 38.

FIG. 6 provides an alternative view of the system 36 without the patient and medical instrument for discussion purposes. As shown, the column 37 may include one or more carriages 43 shown as ring-shaped in the system 36, from which the one or more robotic arms 39 may be based. The carriages 43 may translate along a vertical column interface 44 that runs the length of the column 37 to provide different vantage points from which the robotic arms 39 may be positioned to reach the patient. The carriage(s) 43 may rotate around the column 37 using a mechanical motor positioned within the column 37 to allow the robotic arms 39 to have access to multiples sides of the table 38, such as, for example, both sides of the patient. In embodiments with multiple carriages, the carriages may be individually positioned on the column and may translate and/or rotate independently of the other carriages. While the carriages 43 need not surround the column 37 or even be circular, the ring-shape as shown facilitates rotation of the carriages 43 around the column 37 while maintaining structural balance. Rotation and translation of the carriages 43 allows the system 36 to align the medical instruments, such as endoscopes and laparoscopes, into different access points on the patient. In other embodiments (not shown), the system 36 can include a patient table or bed with adjustable arm supports in the form of bars or rails extending alongside it. One or more robotic arms 39 (e.g., via a shoulder with an elbow joint) can be attached to the adjustable arm supports, which can be vertically adjusted. By providing vertical adjustment, the robotic arms 39 are advantageously capable of being stowed compactly beneath the patient table or bed, and subsequently raised during a procedure.

The robotic arms 39 may be mounted on the carriages 43 through a set of arm mounts 45 comprising a series of joints that may individually rotate and/or telescopically extend to provide additional configurability to the robotic arms 39. Additionally, the arm mounts 45 may be positioned on the carriages 43 such that, when the carriages 43 are appropriately rotated, the arm mounts 45 may be positioned on either the same side of the table 38 (as shown in FIG. 6 ), on opposite sides of the table 38 (as shown in FIG. 9 ), or on adjacent sides of the table 38 (not shown).

The column 37 structurally provides support for the table 38, and a path for vertical translation of the carriages 43. Internally, the column 37 may be equipped with lead screws for guiding vertical translation of the carriages, and motors to mechanize the translation of the carriages 43 based the lead screws. The column 37 may also convey power and control signals to the carriages 43 and the robotic arms 39 mounted thereon.

The table base 46 serves a similar function as the cart base 15 in the cart 11 shown in FIG. 2 , housing heavier components to balance the table/bed 38, the column 37, the carriages 43, and the robotic arms 39. The table base 46 may also incorporate rigid casters to provide stability during procedures. Deployed from the bottom of the table base 46, the casters may extend in opposite directions on both sides of the base 46 and retract when the system 36 needs to be moved.

With continued reference to FIG. 6 , the system 36 may also include a tower (not shown) that divides the functionality of the system 36 between the table and the tower to reduce the form factor and bulk of the table. As in earlier disclosed embodiments, the tower may provide a variety of support functionalities to the table, such as processing, computing, and control capabilities, power, fluidics, and/or optical and sensor processing. The tower may also be movable to be positioned away from the patient to improve physician access and de-clutter the operating room. Additionally, placing components in the tower allows for more storage space in the table base 46 for potential stowage of the robotic arms 39. The tower may also include a master controller or console that provides both a user interface for user input, such as keyboard and/or pendant, as well as a display screen (or touchscreen) for preoperative and intraoperative information, such as real-time imaging, navigation, and tracking information. In some embodiments, the tower may also contain holders for gas tanks to be used for insufflation.

In some embodiments, a table base may stow and store the robotic arms when not in use. FIG. 7 illustrates a system 47 that stows robotic arms in an embodiment of the table-based system. In the system 47, carriages 48 may be vertically translated into base 49 to stow robotic arms 50, arm mounts 51, and the carriages 48 within the base 49. Base covers 52 may be translated and retracted open to deploy the carriages 48, arm mounts 51, and robotic arms 50 around column 53, and closed to stow to protect them when not in use. The base covers 52 may be sealed with a membrane 54 along the edges of its opening to prevent dirt and fluid ingress when closed.

FIG. 8 illustrates an embodiment of a robotically enabled table-based system configured for a ureteroscopic procedure. In a ureteroscopy, the table 38 may include a swivel portion 55 for positioning a patient off-angle from the column 37 and table base 46. The swivel portion 55 may rotate or pivot around a pivot point (e.g., located below the patient's head) in order to position the bottom portion of the swivel portion 55 away from the column 37. For example, the pivoting of the swivel portion 55 allows a C-arm (not shown) to be positioned over the patient's lower abdomen without competing for space with the column (not shown) below table 38. By rotating the carriage 35 (not shown) around the column 37, the robotic arms 39 may directly insert a ureteroscope 56 along a virtual rail 57 into the patient's groin area to reach the urethra. In a ureteroscopy, stirrups 58 may also be fixed to the swivel portion 55 of the table 38 to support the position of the patient's legs during the procedure and allow clear access to the patient's groin area.

In a laparoscopic procedure, through small incision(s) in the patient's abdominal wall, minimally invasive instruments may be inserted into the patient's anatomy. In some embodiments, the minimally invasive instruments comprise an elongated rigid member, such as a shaft, which is used to access anatomy within the patient. After inflation of the patient's abdominal cavity, the instruments may be directed to perform surgical or medical tasks, such as grasping, cutting, ablating, suturing, etc. In some embodiments, the instruments can comprise a scope, such as a laparoscope. FIG. 9 illustrates an embodiment of a robotically enabled table-based system configured for a laparoscopic procedure. As shown in FIG. 9 , the carriages 43 of the system 36 may be rotated and vertically adjusted to position pairs of the robotic arms 39 on opposite sides of the table 38, such that instrument 59 may be positioned using the arm mounts 45 to be passed through minimal incisions on both sides of the patient to reach his/her abdominal cavity.

To accommodate laparoscopic procedures, the robotically enabled table system may also tilt the platform to a desired angle. FIG. 10 illustrates an embodiment of the robotically enabled medical system with pitch or tilt adjustment. As shown in FIG. 10 , the system 36 may accommodate tilt of the table 38 to position one portion of the table at a greater distance from the floor than the other. Additionally, the arm mounts 45 may rotate to match the tilt such that the robotic arms 39 maintain the same planar relationship with the table 38. To accommodate steeper angles, the column 37 may also include telescoping portions 60 that allow vertical extension of the column 37 to keep the table 38 from touching the floor or colliding with the table base 46.

FIG. 11 provides a detailed illustration of the interface between the table 38 and the column 37. Pitch rotation mechanism 61 may be configured to alter the pitch angle of the table 38 relative to the column 37 in multiple degrees of freedom. The pitch rotation mechanism 61 may be enabled by the positioning of orthogonal axes 1, 2 at the column-table interface, each axis actuated by a separate motor 3, 4 responsive to an electrical pitch angle command. Rotation along one screw 5 would enable tilt adjustments in one axis 1, while rotation along the other screw 6 would enable tilt adjustments along the other axis 2. In some embodiments, a ball joint can be used to alter the pitch angle of the table 38 relative to the column 37 in multiple degrees of freedom.

For example, pitch adjustments are particularly useful when trying to position the table in a Trendelenburg position, i.e., position the patient's lower abdomen at a higher position from the floor than the patient's upper abdomen, for lower abdominal surgery. The Trendelenburg position causes the patient's internal organs to slide towards his/her upper abdomen through the force of gravity, clearing out the abdominal cavity for minimally invasive tools to enter and perform lower abdominal surgical or medical procedures, such as laparoscopic prostatectomy.

FIGS. 12 and 13 illustrate isometric and end views of an alternative embodiment of a table-based surgical robotics system 100. The surgical robotics system 100 includes one or more adjustable arm supports 105 that can be configured to support one or more robotic arms (see, for example, FIG. 14 ) relative to a table 101. In the illustrated embodiment, a single adjustable arm support 105 is shown, though an additional arm support can be provided on an opposite side of the table 101. The adjustable arm support 105 can be configured so that it can move relative to the table 101 to adjust and/or vary the position of the adjustable arm support 105 and/or any robotic arms mounted thereto relative to the table 101. For example, the adjustable arm support 105 may be adjusted one or more degrees of freedom relative to the table 101. The adjustable arm support 105 provides high versatility to the system 100, including the ability to easily stow the one or more adjustable arm supports 105 and any robotics arms attached thereto beneath the table 101. The adjustable arm support 105 can be elevated from the stowed position to a position below an upper surface of the table 101. In other embodiments, the adjustable arm support 105 can be elevated from the stowed position to a position above an upper surface of the table 101.

The adjustable arm support 105 can provide several degrees of freedom, including lift, lateral translation, tilt, etc. In the illustrated embodiment of FIGS. 12 and 13 , the arm support 105 is configured with four degrees of freedom, which are illustrated with arrows in FIG. 12 . A first degree of freedom allows for adjustment of the adjustable arm support 105 in the z-direction (“Z-lift”). For example, the adjustable arm support 105 can include a carriage 109 configured to move up or down along or relative to a column 102 supporting the table 101. A second degree of freedom can allow the adjustable arm support 105 to tilt. For example, the adjustable arm support 105 can include a rotary joint, which can allow the adjustable arm support 105 to be aligned with the bed in a Trendelenburg position. A third degree of freedom can allow the adjustable arm support 105 to “pivot up,” which can be used to adjust a distance between a side of the table 101 and the adjustable arm support 105. A fourth degree of freedom can permit translation of the adjustable arm support 105 along a longitudinal length of the table.

The surgical robotics system 100 in FIGS. 12 and 13 can comprise a table supported by a column 102 that is mounted to a base 103. The base 103 and the column 102 support the table 101 relative to a support surface. A floor axis 131 and a support axis 133 are shown in FIG. 13 .

The adjustable arm support 105 can be mounted to the column 102. In other embodiments, the arm support 105 can be mounted to the table 101 or base 103. The adjustable arm support 105 can include a carriage 109, a bar or rail connector 111 and a bar or rail 107. In some embodiments, one or more robotic arms mounted to the rail 107 can translate and move relative to one another.

The carriage 109 can be attached to the column 102 by a first joint 113, which allows the carriage 109 to move relative to the column 102 (e.g., such as up and down a first or vertical axis 123). The first joint 113 can provide the first degree of freedom (“Z-lift”) to the adjustable arm support 105. The adjustable arm support 105 can include a second joint 115, which provides the second degree of freedom (tilt) for the adjustable arm support 105. The adjustable arm support 105 can include a third joint 117, which can provide the third degree of freedom (“pivot up”) for the adjustable arm support 105. An additional joint 119 (shown in FIG. 13 ) can be provided that mechanically constrains the third joint 117 to maintain an orientation of the rail 107 as the rail connector 111 is rotated about a third axis 127. The adjustable arm support 105 can include a fourth joint 121, which can provide a fourth degree of freedom (translation) for the adjustable arm support 105 along a fourth axis 129.

FIG. 14 illustrates an end view of the surgical robotics system 140A with two adjustable arm supports 105A, 105B mounted on opposite sides of a table 101. A first robotic arm 142A is attached to the bar or rail 107A of the first adjustable arm support 105B. The first robotic arm 142A includes a base 144A attached to the rail 107A. The distal end of the first robotic arm 142A includes an instrument drive mechanism 146A that can attach to one or more robotic medical instruments or tools. Similarly, the second robotic arm 142B includes a base 144B attached to the rail 107B. The distal end of the second robotic arm 142B includes an instrument drive mechanism 146B. The instrument drive mechanism 146B can be configured to attach to one or more robotic medical instruments or tools.

In some embodiments, one or more of the robotic arms 142A, 142B comprises an arm with seven or more degrees of freedom. In some embodiments, one or more of the robotic arms 142A, 142B can include eight degrees of freedom, including an insertion axis (1-degree of freedom including insertion), a wrist (3-degrees of freedom including wrist pitch, yaw and roll), an elbow (1-degree of freedom including elbow pitch), a shoulder (2-degrees of freedom including shoulder pitch and yaw), and base 144A, 144B (1-degree of freedom including translation). In some embodiments, the insertion degree of freedom can be provided by the robotic arm 142A, 142B, while in other embodiments, the instrument itself provides insertion via an instrument-based insertion architecture.

C. Instrument Driver & Interface.

The end effectors of the system's robotic arms may comprise (i) an instrument driver (alternatively referred to as “instrument drive mechanism” or “instrument device manipulator”) that incorporates electro-mechanical means for actuating the medical instrument and (ii) a removable or detachable medical instrument, which may be devoid of any electro-mechanical components, such as motors. This dichotomy may be driven by the need to sterilize medical instruments used in medical procedures, and the inability to adequately sterilize expensive capital equipment due to their intricate mechanical assemblies and sensitive electronics. Accordingly, the medical instruments may be designed to be detached, removed, and interchanged from the instrument driver (and thus the system) for individual sterilization or disposal by the physician or the physician's staff. In contrast, the instrument drivers need not be changed or sterilized, and may be draped for protection.

FIG. 15 illustrates an example instrument driver. Positioned at the distal end of a robotic arm, instrument driver 62 comprises one or more drive units 63 arranged with parallel axes to provide controlled torque to a medical instrument via drive shafts 64. Each drive unit 63 comprises an individual drive shaft 64 for interacting with the instrument, a gear head 65 for converting the motor shaft rotation to a desired torque, a motor 66 for generating the drive torque, an encoder 67 to measure the speed of the motor shaft and provide feedback to the control circuitry, and control circuity 68 for receiving control signals and actuating the drive unit. Each drive unit 63 being independently controlled and motorized, the instrument driver 62 may provide multiple (e.g., four as shown in FIG. 15 ) independent drive outputs to the medical instrument. In operation, the control circuitry 68 would receive a control signal, transmit a motor signal to the motor 66, compare the resulting motor speed as measured by the encoder 67 with the desired speed, and modulate the motor signal to generate the desired torque.

For procedures that require a sterile environment, the robotic system may incorporate a drive interface, such as a sterile adapter connected to a sterile drape, that sits between the instrument driver and the medical instrument. The chief purpose of the sterile adapter is to transfer angular motion from the drive shafts of the instrument driver to the drive inputs of the instrument while maintaining physical separation, and thus sterility, between the drive shafts and drive inputs. Accordingly, an example sterile adapter may comprise a series of rotational inputs and outputs intended to be mated with the drive shafts of the instrument driver and drive inputs on the instrument. Connected to the sterile adapter, the sterile drape, comprised of a thin, flexible material such as transparent or translucent plastic, is designed to cover the capital equipment, such as the instrument driver, robotic arm, and cart (in a cart-based system) or table (in a table-based system). Use of the drape would allow the capital equipment to be positioned proximate to the patient while still being located in an area not requiring sterilization (i.e., non-sterile field). On the other side of the sterile drape, the medical instrument may interface with the patient in an area requiring sterilization (i.e., sterile field).

D. Medical Instrument.

FIG. 16 illustrates an example medical instrument with a paired instrument driver. Like other instruments designed for use with a robotic system, medical instrument 70 comprises an elongated shaft 71 (or elongate body) and an instrument base 72. The instrument base 72, also referred to as an “instrument handle” due to its intended design for manual interaction by the physician, may generally comprise rotatable drive inputs 73, e.g., receptacles, pulleys or spools, that are designed to be mated with drive outputs 74 that extend through a drive interface on instrument driver 75 at the distal end of robotic arm 76. When physically connected, latched, and/or coupled, the mated drive inputs 73 of the instrument base 72 may share axes of rotation with the drive outputs 74 in the instrument driver 75 to allow the transfer of torque from the drive outputs 74 to the drive inputs 73. In some embodiments, the drive outputs 74 may comprise splines that are designed to mate with receptacles on the drive inputs 73.

The elongated shaft 71 is designed to be delivered through either an anatomical opening or lumen, e.g., as in endoscopy, or a minimally invasive incision, e.g., as in laparoscopy. The elongated shaft 71 may be either flexible (e.g., having properties similar to an endoscope) or rigid (e.g., having properties similar to a laparoscope) or contain a customized combination of both flexible and rigid portions. When designed for laparoscopy, the distal end of a rigid elongated shaft may be connected to an end effector extending from a jointed wrist formed from a clevis with at least one degree of freedom and a surgical tool or medical instrument, such as, for example, a grasper or scissors, that may be actuated based on force from the tendons as the drive inputs rotate in response to torque received from the drive outputs 74 of the instrument driver 75. When designed for endoscopy, the distal end of a flexible elongated shaft may include a steerable or controllable bending section that may be articulated and bent based on torque received from the drive outputs 74 of the instrument driver 75.

Torque from the instrument driver 75 is transmitted down the elongated shaft 71 using tendons along the elongated shaft 71. These individual tendons, such as pull wires, may be individually anchored to individual drive inputs 73 within the instrument handle 72. From the handle 72, the tendons are directed down one or more pull lumens along the elongated shaft 71 and anchored at the distal portion of the elongated shaft 71, or in the wrist at the distal portion of the elongated shaft. During a surgical procedure, such as a laparoscopic, endoscopic or hybrid procedure, these tendons may be coupled to a distally mounted end effector, such as a wrist, grasper, or scissor. Under such an arrangement, torque exerted on drive inputs 73 would transfer tension to the tendon, thereby causing the end effector to actuate in some way. In some embodiments, during a surgical procedure, the tendon may cause a joint to rotate about an axis, thereby causing the end effector to move in one direction or another. Alternatively, the tendon may be connected to one or more jaws of a grasper at the distal end of the elongated shaft 71, where tension from the tendon causes the grasper to close.

In endoscopy, the tendons may be coupled to a bending or articulating section positioned along the elongated shaft 71 (e.g., at the distal end) via adhesive, control ring, or other mechanical fixation. When fixedly attached to the distal end of a bending section, torque exerted on the drive inputs 73 would be transmitted down the tendons, causing the softer, bending section (sometimes referred to as the articulable section or region) to bend or articulate. Along the non-bending sections, it may be advantageous to spiral or helix the individual pull lumens that direct the individual tendons along (or inside) the walls of the endoscope shaft to balance the radial forces that result from tension in the pull wires. The angle of the spiraling and/or spacing therebetween may be altered or engineered for specific purposes, wherein tighter spiraling exhibits lesser shaft compression under load forces, while lower amounts of spiraling results in greater shaft compression under load forces, but limits bending. On the other end of the spectrum, the pull lumens may be directed parallel to the longitudinal axis of the elongated shaft 71 to allow for controlled articulation in the desired bending or articulable sections.

In endoscopy, the elongated shaft 71 houses a number of components to assist with the robotic procedure. The shaft 71 may comprise a working channel for deploying surgical tools (or medical instruments), irrigation, and/or aspiration to the operative region at the distal end of the shaft 71. The shaft 71 may also accommodate wires and/or optical fibers to transfer signals to/from an optical assembly at the distal tip, which may include an optical camera. The shaft 71 may also accommodate optical fibers to carry light from proximally located light sources, such as light emitting diodes, to the distal end of the shaft 71.

At the distal end of the instrument 70, the distal tip may also comprise the opening of a working channel for delivering tools for diagnostic and/or therapy, irrigation, and aspiration to an operative site. The distal tip may also include a port for a camera, such as a fiberscope or a digital camera, to capture images of an internal anatomical space. Relatedly, the distal tip may also include ports for light sources for illuminating the anatomical space when using the camera.

In the example of FIG. 16 , the drive shaft axes, and thus the drive input axes, are orthogonal to the axis of the elongated shaft 71. This arrangement, however, complicates roll capabilities for the elongated shaft 71. Rolling the elongated shaft 71 along its axis while keeping the drive inputs 73 static results in undesirable tangling of the tendons as they extend off the drive inputs 73 and enter pull lumens within the elongated shaft 71. The resulting entanglement of such tendons may disrupt any control algorithms intended to predict movement of the flexible elongated shaft 71 during an endoscopic procedure.

FIG. 17 illustrates an alternative design for an instrument driver and instrument where the axes of the drive units are parallel to the axis of the elongated shaft of the instrument. As shown, a circular instrument driver 80 comprises four drive units with their drive outputs 81 aligned in parallel at the end of a robotic arm 82. The drive units, and their respective drive outputs 81, are housed in a rotational assembly 83 of the instrument driver 80 that is driven by one of the drive units within the assembly 83. In response to torque provided by the rotational drive unit, the rotational assembly 83 rotates along a circular bearing that connects the rotational assembly 83 to the non-rotational portion 84 of the instrument driver 80. Power and controls signals may be communicated from the non-rotational portion 84 of the instrument driver 80 to the rotational assembly 83 through electrical contacts that may be maintained through rotation by a brushed slip ring connection (not shown). In other embodiments, the rotational assembly 83 may be responsive to a separate drive unit that is integrated into the non-rotatable portion 84, and thus not in parallel to the other drive units. The rotational mechanism 83 allows the instrument driver 80 to rotate the drive units, and their respective drive outputs 81, as a single unit around an instrument driver axis 85.

Like earlier disclosed embodiments, an instrument 86 may comprise an elongated shaft portion 88 and an instrument base 87 (shown with a transparent external skin for discussion purposes) comprising a plurality of drive inputs 89 (such as receptacles, pulleys, and spools) that are configured to receive the drive outputs 81 in the instrument driver 80. Unlike prior disclosed embodiments, the instrument shaft 88 extends from the center of the instrument base 87 with an axis substantially parallel to the axes of the drive inputs 89, rather than orthogonal as in the design of FIG. 16 .

When coupled to the rotational assembly 83 of the instrument driver 80, the medical instrument 86, comprising instrument base 87 and instrument shaft 88, rotates in combination with the rotational assembly 83 about the instrument driver axis 85. Since the instrument shaft 88 is positioned at the center of instrument base 87, the instrument shaft 88 is coaxial with instrument driver axis 85 when attached. Thus, rotation of the rotational assembly 83 causes the instrument shaft 88 to rotate about its own longitudinal axis. Moreover, as the instrument base 87 rotates with the instrument shaft 88, any tendons connected to the drive inputs 89 in the instrument base 87 are not tangled during rotation. Accordingly, the parallelism of the axes of the drive outputs 81, drive inputs 89, and instrument shaft 88 allows for the shaft rotation without tangling any control tendons.

FIG. 18 illustrates an instrument having an instrument based insertion architecture in accordance with some embodiments. The instrument 150 can be coupled to any of the instrument drivers discussed above. The instrument 150 comprises an elongated shaft 152, an end effector 162 connected to the shaft 152, and a handle 170 coupled to the shaft 152. The elongated shaft 152 comprises a tubular member having a proximal portion 154 and a distal portion 156. The elongated shaft 152 comprises one or more channels or grooves 158 along its outer surface. The grooves 158 are configured to receive one or more wires or cables 180 therethrough. One or more cables 180 thus run along an outer surface of the elongated shaft 152. In other embodiments, cables 180 can also run through the elongated shaft 152. Manipulation of the one or more cables 180 (e.g., via an instrument driver) results in actuation of the end effector 162.

The instrument handle 170, which may also be referred to as an instrument base, may generally comprise an attachment interface 172 having one or more mechanical inputs 174, e.g., receptacles, pulleys or spools, that are designed to be reciprocally mated with one or more torque couplers on an attachment surface of an instrument driver.

In some embodiments, the instrument 150 comprises a series of pulleys or cables that enable the elongated shaft 152 to translate relative to the handle 170. In other words, the instrument 150 itself comprises an instrument-based insertion architecture that accommodates insertion of the instrument, thereby minimizing the reliance on a robot arm to provide insertion of the instrument 150. In other embodiments, a robotic arm can be largely responsible for instrument insertion.

E. Controller.

Any of the robotic systems described herein can include an input device or controller for manipulating an instrument attached to a robotic arm. In some embodiments, the controller can be coupled (e.g., communicatively, electronically, electrically, wirelessly and/or mechanically) with an instrument such that manipulation of the controller causes a corresponding manipulation of the instrument e.g., via master slave control.

FIG. 19 is a perspective view of an embodiment of a controller 182. In the present embodiment, the controller 182 comprises a hybrid controller that can have both impedance and admittance control. In other embodiments, the controller 182 can utilize just impedance or passive control. In other embodiments, the controller 182 can utilize just admittance control. By being a hybrid controller, the controller 182 advantageously can have a lower perceived inertia while in use.

In the illustrated embodiment, the controller 182 is configured to allow manipulation of two medical instruments, and includes two handles 184. Each of the handles 184 is connected to a gimbal 186. Each gimbal 186 is connected to a positioning platform 188.

As shown in FIG. 19 , each positioning platform 188 includes a SCARA arm (selective compliance assembly robot arm) 198 coupled to a column 194 by a prismatic joint 196. The prismatic joints 196 are configured to translate along the column 194 (e.g., along rails 197) to allow each of the handles 184 to be translated in the z-direction, providing a first degree of freedom. The SCARA arm 198 is configured to allow motion of the handle 184 in an x-y plane, providing two additional degrees of freedom.

In some embodiments, one or more load cells are positioned in the controller. For example, in some embodiments, a load cell (not shown) is positioned in the body of each of the gimbals 186. By providing a load cell, portions of the controller 182 are capable of operating under admittance control, thereby advantageously reducing the perceived inertia of the controller while in use. In some embodiments, the positioning platform 188 is configured for admittance control, while the gimbal 186 is configured for impedance control. In other embodiments, the gimbal 186 is configured for admittance control, while the positioning platform 188 is configured for impedance control. Accordingly, for some embodiments, the translational or positional degrees of freedom of the positioning platform 188 can rely on admittance control, while the rotational degrees of freedom of the gimbal 186 rely on impedance control.

F. Navigation and Control.

Traditional endoscopy may involve the use of fluoroscopy (e.g., as may be delivered through a C-arm) and other forms of radiation-based imaging modalities to provide endoluminal guidance to an operator physician. In contrast, the robotic systems contemplated by this disclosure can provide for non-radiation-based navigational and localization means to reduce physician exposure to radiation and reduce the amount of equipment within the operating room. As used herein, the term “localization” may refer to determining and/or monitoring the position of objects in a reference coordinate system. Technologies such as preoperative mapping, computer vision, real-time EM tracking, and robot command data may be used individually or in combination to achieve a radiation-free operating environment. In other cases, where radiation-based imaging modalities are still used, the preoperative mapping, computer vision, real-time EM tracking, and robot command data may be used individually or in combination to improve upon the information obtained solely through radiation-based imaging modalities.

FIG. 20 is a block diagram illustrating a localization system 90 that estimates a location of one or more elements of the robotic system, such as the location of the instrument, in accordance to an example embodiment. The localization system 90 may be a set of one or more computer devices configured to execute one or more instructions. The computer devices may be embodied by a processor (or processors) and computer-readable memory in one or more components discussed above. By way of example and not limitation, the computer devices may be in the tower 30 shown in FIG. 1 , the cart 11 shown in FIGS. 1-4 , the beds shown in FIGS. 5-14 , etc.

As shown in FIG. 20 , the localization system 90 may include a localization module 95 that processes input data 91-94 to generate location data 96 for the distal tip of a medical instrument. The location data 96 may be data or logic that represents a location and/or orientation of the distal end of the instrument relative to a frame of reference. The frame of reference can be a frame of reference relative to the anatomy of the patient or to a known object, such as an EM field generator (see discussion below for the EM field generator).

The various input data 91-94 are now described in greater detail. Preoperative mapping may be accomplished through the use of the collection of low dose CT scans. Preoperative CT scans are reconstructed into three-dimensional images, which are visualized, e.g. as “slices” of a cutaway view of the patient's internal anatomy. When analyzed in the aggregate, image-based models for anatomical cavities, spaces and structures of the patient's anatomy, such as a patient lung network, may be generated. Techniques such as center-line geometry may be determined and approximated from the CT images to develop a three-dimensional volume of the patient's anatomy, referred to as model data 91 (also referred to as “preoperative model data” when generated using only preoperative CT scans). The use of center-line geometry is discussed in U.S. patent application Ser. No. 14/523,760, the contents of which are herein incorporated in its entirety. Network topological models may also be derived from the CT-images, and are particularly appropriate for bronchoscopy.

In some embodiments, the instrument may be equipped with a camera to provide vision data (or image data) 92. The localization module 95 may process the vision data 92 to enable one or more vision-based (or image-based) location tracking modules or features. For example, the preoperative model data 91 may be used in conjunction with the vision data 92 to enable computer vision-based tracking of the medical instrument (e.g., an endoscope or an instrument advance through a working channel of the endoscope). For example, using the preoperative model data 91, the robotic system may generate a library of expected endoscopic images from the model based on the expected path of travel of the endoscope, each image linked to a location within the model. Intraoperatively, this library may be referenced by the robotic system in order to compare real-time images captured at the camera (e.g., a camera at a distal end of the endoscope) to those in the image library to assist localization.

Other computer vision-based tracking techniques use feature tracking to determine motion of the camera, and thus the endoscope. Some features of the localization module 95 may identify circular geometries in the preoperative model data 91 that correspond to anatomical lumens and track the change of those geometries to determine which anatomical lumen was selected, as well as the relative rotational and/or translational motion of the camera. Use of a topological map may further enhance vision-based algorithms or techniques.

Optical flow, another computer vision-based technique, may analyze the displacement and translation of image pixels in a video sequence in the vision data 92 to infer camera movement. Examples of optical flow techniques may include motion detection, object segmentation calculations, luminance, motion compensated encoding, stereo disparity measurement, etc. Through the comparison of multiple frames over multiple iterations, movement and location of the camera (and thus the endoscope) may be determined.

The localization module 95 may use real-time EM tracking to generate a real-time location of the endoscope in a global coordinate system that may be registered to the patient's anatomy, represented by the preoperative model. In EM tracking, an EM sensor (or tracker) comprising one or more sensor coils embedded in one or more locations and orientations in a medical instrument (e.g., an endoscopic tool) measures the variation in the EM field created by one or more static EM field generators positioned at a known location. The location information detected by the EM sensors is stored as EM data 93. The EM field generator (or transmitter), may be placed close to the patient to create a low intensity magnetic field that the embedded sensor may detect. The magnetic field induces small currents in the sensor coils of the EM sensor, which may be analyzed to determine the distance and angle between the EM sensor and the EM field generator. These distances and orientations may be intraoperatively “registered” to the patient anatomy (e.g., the preoperative model) in order to determine the geometric transformation that aligns a single location in the coordinate system with a position in the preoperative model of the patient's anatomy. Once registered, an embedded EM tracker in one or more positions of the medical instrument (e.g., the distal tip of an endoscope) may provide real-time indications of the progression of the medical instrument through the patient's anatomy.

Robotic command and kinematics data 94 may also be used by the localization module 95 to provide localization data 96 for the robotic system. Device pitch and yaw resulting from articulation commands may be determined during preoperative calibration. Intraoperatively, these calibration measurements may be used in combination with known insertion depth information to estimate the position of the instrument. Alternatively, these calculations may be analyzed in combination with EM, vision, and/or topological modeling to estimate the position of the medical instrument within the network.

As FIG. 20 shows, a number of other input data can be used by the localization module 95. For example, although not shown in FIG. 20 , an instrument utilizing shape-sensing fiber can provide shape data that the localization module 95 can use to determine the location and shape of the instrument.

The localization module 95 may use the input data 91-94 in combination(s). In some cases, such a combination may use a probabilistic approach where the localization module 95 assigns a confidence weight to the location determined from each of the input data 91-94. Thus, where the EM data may not be reliable (as may be the case where there is EM interference) the confidence of the location determined by the EM data 93 can be decrease and the localization module 95 may rely more heavily on the vision data 92 and/or the robotic command and kinematics data 94.

As discussed above, the robotic systems discussed herein may be designed to incorporate a combination of one or more of the technologies above. The robotic system's computer-based control system, based in the tower, bed and/or cart, may store computer program instructions, for example, within a non-transitory computer-readable storage medium such as a persistent magnetic storage drive, solid state drive, or the like, that, upon execution, cause the system to receive and analyze sensor data and user commands, generate control signals throughout the system, and display the navigational and localization data, such as the position of the instrument within the global coordinate system, anatomical map, etc.

2. Clip-Applier and Clips.

Embodiments of the disclosure relate to systems and techniques for applying clips to ligate tissue. Medical clips can be used in a variety of different medical procedures, including, for example, laparoscopic procedures in which the medical clips may be used to ligate and/or seal tissue to stop bleeding. The use of clips to ligate tissue can be advantageous as they can be faster than the use of sutures to ligate tissue. When used as part of a robotic system, it can be desirable to provide a one or more of degrees of freedom (DOF) of movement at an articulating wrist of the medical clip applier. It can also be desirable for the clip applier to multi-fire wherein multiple clips are preloaded into the instrument. Multiple clips applied from a single instrument allows multiple clips to quickly be applied in succession while keeping the applier at the target tissue, without reloading the applier. Embodiments of the disclosure herein relate to the use of medical clips as part of a robotic system and in certain embodiments, the robotic system can provide one or more of degrees of freedom (DOF) of movement at an articulating wrist of an end effector that is configured to apply one or more medical clips. Certain embodiments can be configured with an end effector that includes multiple clips that are preloaded into a cartridge such that the a plurality of clips can be delivered. Multiple clips applied from a single end effector can allow multiple clips to quickly be applied in succession while keeping the effector at the target tissue, without having to reload. Such an instrument that can deliver multiple clips in succession can be referred to as a multi-fire clip applier. Advantageously, in some embodiments, the multi-fire clip can deliver a multitude of clips in succession without having to reload the clips.

There are a number of challenges in providing a robotically controlled multi-fire clip applier. As it is desired to reduce the size of incisions formed in a patient, instruments are becoming increasingly smaller in size. Robotic instruments incorporate a number of pulleys and cables, thereby reducing the overall available space within the instruments. As these instruments increase their number of DOFs (e.g., from a single DOF wrist to a multi-DOF wrist), thereby increasing the complexity of the pulleys and cables within the instruments, these size constraints are exacerbated.

One example of a surgery that can apply a multi-fire clip applier is a colon resection, wherein a portion of a colon is removed. In such a procedure, a multi-fire clip end effector can apply first and second clips on one side of a colon portion to be resected, and a third clip on another side of the colon portion to be resected. The first and second clips can be applied to the high-pressure side. Tissue may be cut in the space between the second and third clips.

Another example of a surgery that can apply a multi-fire clip applier is a laparoscopic cholecystectomy, wherein a gall bladder of a patient is removed. In such a procedure, a multi-fire clip applier can apply first and second clips on one side of a cystic duct away from the gall bladder near the common bile duct, and a third clip on another side of the cystic duct nearer the gall bladder. The cystic duct may be cut in the space between the second and third clips. The gall bladder may be removed with the first and second clips providing redundant ligation security on the cystic duct near the common bile duct, while the third clip near the gall bladder keeps bile and stones from disgorging during the removal of the gall bladder.

FIG. 21 illustrates an example embodiment of a medical instrument 200 in accordance with aspects of this disclosure. In the embodiment illustrated in FIG. 21 , the medical instrument 200 can be a robotically controlled surgical instrument that can include a shaft 205, a handle 210, and an end effector 215. The instrument 200 can be coupled to any of the instrument drivers discussed above. One or more cables (not illustrated) can run along an outer surface of the shaft 205 and/or one or more cables can also run through the elongated shaft 205. Manipulation of the one or more cables (e.g., via an instrument driver) results in actuation of the end effector 215.

The handle 210, which may also be referred to as an instrument base, may generally include an attachment interface having one or more mechanical inputs, e.g., receptacles, pulleys or spools, that are designed to be reciprocally mated with one or more torque couplers on an attachment surface of an instrument driver.

Depending on the implementation of the particular instrument 200, the end effector 215 may be embodied to perform one or more different medical and/or surgical tasks, which can be effectuated via tensioning the one or more cables. In some embodiments, the instrument 200 comprises a series of pulleys to which the one or more cables can be operatively coupled that enable the shaft 205 to translate relative to the handle 210.

In some embodiments, the instrument 200 may include an end effector 215 that is adapted to apply one or more clips adapted to grip and to close onto tissue, and in certain embodiments the end effector 216 is coupled to a wrist providing at least one degree of freedom of movement.

FIGS. 22A-22D illustrate an example embodiment of a novel clip 300 to be fired from a clip applier, as discussed above. FIGS. 22A and 22B illustrate front perspective views of the clip 300. FIGS. 22C and 23D illustrate side perspective views of the clip 300. FIGS. 22A and 22C illustrate the clip 300 in an open position. FIGS. 22B and 22D illustrate the clip 300 in a closed position.

The clip 300 can include a first arm 320 and a second arm 330. A proximal end of the first arm 320 and a proximal end of the second arm 330 can be joined to form a vertex 310. The vertex 310 may include one or more loops 312. The loops 312 of the vertex 310 may form a spring, such as a torsion spring formed by the one or more loops or coils. The spring may be biased to bias the first arm 320 and second arm 330 towards each other in the closed position. The clip 300 may use the spring to assist with the automatic closing. The use of at least one complete loop 312 at the vertex 310 also advantageously prevents any gap or unclamped area between the first arm 320 and second arm 330 when the clip 300 is in the closed position. Therefore, when the clip 300 is closed on tissue, the tissue received in the clip 300 is fully ligated. Advantageously, the illustrated embodiment of the clip 300 can create an overlap between first arm 320 and second arm 330 that result in no gap near the vertex 310.

As shown in FIGS. 22A and 22B, the first arm 320 can be formed of a single strut 322 while the second arm 330 can be formed by a pair of struts including a second strut 332 and a third strut 334. The distal end of the first strut 322 of the first arm 320 may form a first loop 340. The distal ends of the second strut 332 and the third strut 334 of the second arm 330 may meet to form a second loop 350. The first loop 340 may be smaller in diameter than the second loop 350 such that the first loop 340 can fit within the second loop 350 as shown in FIG. 22B. In other embodiments, the distal end of the first arm 320 may form a first tab (not shown) and the distal end of the second arm 330 may form a second tab (not shown) that can abut against each other in a closed position. In some embodiments, the first strut 322 can overlap and cross beyond the second and third struts 332, 334 in the closed configuration. In other words, in a closed configuration, first strut 322 can advantageously pass slightly beyond a plane formed by second and third struts 332, 334. This overlap advantageously helps to ensure that a vessel/lumen/duct/tissue that is clipped by a clip will not leak.

The first loop 340 may be aligned with the length of the first strut 322. The length of the first loop 340 may also be aligned with an axis not parallel to the length of the first strut 322. Similarly, the length of the second loop 350 may aligned with an axis not parallel to the length of the second and third struts 332, 334. For example, the length of the first loop 340 and length of the second loop may be configured to be parallel with each other when the clip 300 is in a fully open position, as shown in FIG. 22A. Similarly, the length of the first loop 340 and the length of the second loop 350 can be configured to form an acute angle when the clip 300 is in the closed position, as shown in FIG. 22D.

In the open position, the distal end of the first arm 320 and the distal end of the second arm 330 are separated from each other. In the open position, such as shown in FIGS. 22A and 22C, the first loop 340 of the first arm 320 and the second loop 350 of the second arm 330 are separated from each other. In the closed position, such as shown in FIGS. 22B and 22D, the distal end of the first arm 320 and the distal end of the second arm 330 are intermeshed with each other. In the closed position, the first loop 340 of the first arm 320 and the second loop 350 of the second arm 330 are intermeshed with each other. In some embodiments, the first loop 340 may be received within the second loop 350 when the clip 300 is in the closed position. In particular, this is seen in FIG. 22D, where the first loop 340 extends past the second loop 350. In some embodiments, the single strut 322 of the first arm 320 may be received between the pair of struts 332, 334 of the second arm 330 when the clip 300 is in the closed position. As shown in FIG. 22E, the first arm 320 may extend past or beyond the second arm 330 in the closed position. The clip 300 may have a center plane from the center of the vertex 310, such that each of the first arm 320 and second arm 330 are equally spaced at each point along their respective lengths from the center plane when the clip 300 is in the open position. The center plane may bisect the clip 300 such that each of the first arm 320 and the second arm 330 are equally angled from the center plane in the open position. In the closed position, each of the first arm 320 and the second arm 330 pass the center plane. As described previously, the first arm 320 may be formed by a single strut 322 and the second arm 330 can be formed by a pair of struts, the second strut 332 and third strut 334. In the closed position, the first strut 322 may pass between and beyond the second and third struts 332, 334. The first arm 320 and the second arm 330 may pass beyond each other to form an angle relative to each other.

FIG. 23 illustrates the clip 300 positioned closed on a vessel 302. The clip 300 is configured to lock or over-close at the distal end of the clip 300 as described herein, so that the clip 300 will not slip off of the vessel 302. In the closed configuration, the clip 300 is designed such that the distal loop 340 of the first arm 320 interlocks, intermeshes, or interdigitates with the distal loop 350 of the second arm 330. This is enabled by having the distal loop 340 of the first arm 320 be of a relatively smaller size than the distal loop 350 of the second arm 330, thereby allowing the distal loop 340 of the first arm 320 to pass through the distal loop 350 of the second arm 330. By including distal portions of the arms that interlock with one another, the clip 300 provides a secure grip of a vessel 302, as shown in FIG. 23 .

In addition to the distal loops 340, 350 interlocking, the first arm 320 is formed of one strut 322, while the second arm 330 is formed of two struts 332, 334. Accordingly, the clip 300 uses three clamping struts for ligation. In this embodiment, the single strut 322 passes between and through two struts 332, 334. When vessel is caught between the first and second arms 320, 330 of the clip 300, the vessel 302 is forced into a zig-zag shape which advantageously increases ligation security.

FIGS. 24A and 24B illustrate another embodiment of a clip 400 that can be used to ligate tissue. As shown in FIGS. 24A and 24B, the clip 400 in the illustrated embodiment includes a first arm 420 and a second arm 430. The first arm 420 and second arm 430 may each include one strut or member 422, 432, as shown in FIGS. 25A-25B. The first arm 420 and second arm 430 may be connected or joined at one end to form a vertex 410. A proximal end of the first arm 420 and a proximal end of the second arm 430 can be joined to form the vertex 410. The vertex 410 may include one or more loops 412. The one or more loops of the vertex 410 form include a spring, such as a torsion spring. The torsion spring may be biased to bias the first arm 420 and second arm 430 towards each other in the closed position. The clip 400 may use a multi-coil spring to assist with the automatic closing. The clip 400 may be configured as described above with at least one loop 412 to advantageously prevent any gap or unclamped area between the first arm 420 and the second arm 430.

The distal end of the first arm 420 may include a first clamp 440. The distal end of the second arm 430 may include a second clamp 450. The first clamp 440 and second clamp 450 may be configured to interlink or interlock with each other when the clip 400 is in the closed position. The first clamp 440 and the second clamp 450 may be cup shaped or “U” shaped such that there is an open face and a closed face of each clamp as well as a first side and a second side of each clamp. The first clamp 440 and second clamp 450 may be oriented in opposite directions such that when the clip 400 is in a closed position, the open faces of the first clamp 440 and the second clamp 450 may interlock with each other.

The first clamp 440 may be offset from the first arm 420 in a first direction. For example, the first side of the first clamp 440 may be connected to the strut 422 of the first arm 420. Similarly, the second clamp 450 may be offset from the second arm 430 in an opposite direction from the first direction. For example, the second side of the second clamp 450 may be connected to the strut 432 of the second arm 430. With this configuration, the first arm 420 and the second arm 430 are in secured closely together with each other when the first clamp 40 and the second clamp 450 are interlocked in the closed position.

FIGS. 25A-25C illustrate an embodiment of a cartridge 500 that holds and dispenses one or more clips, such as the clips 300, 400 as described herein. The cartridge 500 may be disposable, such that the cartridge 500 is intended to be thrown away after each use. The cartridge 500 may also be rechargeable, such that the cartridge 500 may be sterilized and reloaded with one or more clips to be reused. Additionally, some components of the cartridge 500 may be disposable while others are rechargeable.

The cartridge 500 can be removably coupled to the robotic arm. The robotic arm may include an elongate shaft (as described above) extending between a proximal end and a distal end, and a wrist 600 extending from the distal end of the elongate shaft. The wrist 600 may be used in combination with the robotic system as described above. The wrist 600 may provide at least one degree of freedom to actuate and/or dispense the one or more clips out of the cartridge 500 along an actuation axis 550 and certain embodiments the wrist 600 can provide at least one degree of freedom of movement. In some embodiments, the wrist 600 may provide at least two degrees of freedom (e.g., a proximal pitch and a distal yaw) to actuate and/or dispense one or more clips out of a cartridge along an actuation axis. For example, in the illustrated embodiment the wrist 600 can be configured to rotate the cartridge 500 about at least a first axis and in certain embodiments also about second axis. An advantage of the illustrated embodiment, is that a clip and/or multiple clips can be dispensed with only one degree of movement or actuation. By utilizing one degree of freedom of movement for dispensing the clips, remaining cables and/or pulleys can be used to provide for one or degrees of freedom of movement.

As noted above, the wrist 600 may provide more than one degree of freedom, such as two degrees of freedom. In certain arrangements, the elongate shaft may provide one degree of freedom, such that the shaft may be translated along the one degree of freedom, such as along an insertion or retraction axis, such as the actuation axis 550. The wrist 600 may also include one or more pulleys 650, which may receive one or more cables capable of moving an actuator to advance one or more clips through the cartridge 500. In this manner, the wrist 600 may actuate deployment of the one or more clips from the cartridge 500, wherein the one or more clips are capable of being both delivered and automatically clipped by the one degree of freedom movement of the actuator.

As shown in FIG. 25A, the cartridge 500 may include a first plate 530 and a second plate 540 on opposing sides of the cartridge 500, such as on the top side and bottom side. The cartridge 500 may include a first channel or track 510 and a second channel or track 520 on opposing sides of the cartridge 500 as shown in FIG. 25C. The first track 510 can receive or engage with the first loops 340 of the one or more clips 300. The second track 520 may receive or engage with the second loops 350 of the one or more clips 300. Advantageously, by having the tracks engage with the loops, this helps to keep the clips open as they translate along the cartridge. The first track 510 and second track 520 may be separated on either side of the cartridge 500. The tracks 510, 520 may be configured to hold each of the plurality of clips 300 in an open position, such that the distal ends or loops of each of the clips 300 are separated from each other. When each clip 300 is actuated to be pushed out of the distal end of the cartridge 500, the clip 300 dispensed will snap shut in a closed position, such that the distal ends of each clip 300 are positioned close to each other, such as where the distal ends are interlocked with each other as described above.

The one or more clips 300 may be configured to automatically shut when dispensed from the cartridge 500. As discussed herein, the clip 300 may include a torsion spring where the arms of the clip 300 are biased towards each other in the closed position an can assist with automatic closing. This is advantageous as other instruments may not have clips that are automatically shut, thereby utilizing at least two types of actuation to both translate and shut a clip that is deployed from a clip applier.

FIG. 26 illustrates the cartridge 500 with the second plate 540 removed. As shown in FIG. 26 , the cartridge 500 may hold four clips 300 in a nested configuration within the cartridge 500. The cartridge 500 may also include between one, two, three, four or more than four clips 300. As described previously, the first loops 340 of the clips 300 may be held in a first channel 510 while the second loops 350 of the clips 300 may be held in a second channel 520. The clips 300 may be nested such that the clips 300 are placed close to each other within the cartridge 500. The thickness of the clips 300 can be minimized so that clips 300 may be placed close together in a skeletonized area of the cartridge 500. Additionally, the minimized thickness of the clips 300 can also advantageously provide greater visibility for the surgeon to see around the one or more clips 300. The clips 300 having a three arm configuration where a first arm 320 having one strut 322 and a second arm 330 having two struts 332, 334 also allows the plurality of clips 300 to next closely together.

The nesting configuration allows the one or more clips to be loaded or packed into the cartridge 500. The nesting configuration advantageously allow the cartridge 500 length to be reduced than if the one or more clips were laid end to end. For example, the cartridge 500 may be reduced by 55%, 65%, 75% or more.

FIGS. 27A and 27B illustrate side views of the cartridge 500 wherein portions of the outer housing is transparent. As shown in FIG. 27A, the first track 510 may include a series of one or more ratchet elements such as tangs or prongs 514 configured to hold each clip 300 in place along the length of the cartridge 500. The ratchet elements are also configured to only allow the clips 300 to move in one direction, and thus prevent clips from moving in a backwards direction.

The first track 510 may include ratchet elements such as a series of tangs or prongs 514. The prongs 514 may be positioned on only one side of the first track 510, as shown on the bottom side of the first track 510 in FIG. 27A. In other embodiments, the first track 510 may also include a second series of ratchet elements such as prongs 524, on the other side of the first track 510, such as the top side. The second prongs 524 may be configured to actuate movement of the clips 300 out of the distal end of the cartridge 500. The second prongs 524 may be similarly structured to the first prongs 514, to only allow a one way ratchet motion. The second prongs 524 may act as an actuator to actuate the one or more clips along the tracks of the cartridge 500. For example, the second prongs 524 may be advanced by actuating a pulley, as described more below. The prongs 514, 524 of the first track 510 may be configured to engage with the first distal loops 340 of the clips 300. Similarly, as shown in FIG. 27B, the second track 520 may include a first series of one or more prongs or tangs 514 configured to hold each clip 300 in place along the length of the cartridge 500. Similarly, the second track 520 may include a set of second prongs 524 configured to actuate movement of the clips 300 out of the distal end of the cartridge 500. The prongs 514, 524 of the second track 520 may be configured to engage with the second distal loops 350 of the clips 300.

As described previously, the prongs 514, 524 may be configured to prevent the clips 300 from moving in a reverse direction or backing up. The prongs 514, 524 are oriented in a first angle and direction such that when each clip 300 is advanced forward (toward the distal end of the cartridge 500), the distal loops 340, 350 push the prongs 514, 524 of the tracks 510, 520 down, such that the distal loops 340, 350 may slide over the prongs 514, 524 of the tracks 510, 520. When the distal loops 340, 350 of the clips 300 have advanced past the prongs 514, 524, the prongs 514, 524 pop back up. The prongs 514, 524 oriented at an angle prevent the distal loops 340, 350 from sliding back in a reverse direction.

The channels or tracks 510, 520 may hold the clips 300 open and in place until the clip 300 is positioned at the end of each channel or track 510, 520. When the first and second loops 340, 350 of the clip 300 reach the end of the tracks 510, 520, an incremental push moves the first and second loops 340, 350 out of the tracks 510, 520 and the clip 300 snaps closed. This incremental push may come from an actuator pushing the first clip at one end of the cartridge 500, which in turn pushes the remainder of the plurality of clips, to push the last clip positioned at the end of the tracks 510, 520 out of the cartridge 500. The clips 300 may also be advanced through movement of the first plate 530 or second plate 540. The first plate 530 or second plate 540 may be advanced forward and backwards to advance each clip 300. For example, the second plate 540 may be actuated to move the one or more clips forward while the first plate 530 remains static.

FIGS. 28A and 28B illustrate side views of the cartridge 500 wherein portions of the outer housing is removed. As shown in FIGS. 28A and 28B, where the first plate 530 is removed, the and second prongs 524 may be connected or integral with the second plate 540. As shown in FIG. 28B, the pulley 650 may include a pin 655 that is received within a slot 545 of the second plate 540. As the pulley 650 is actuated to rotate, the second plate 540 may be advanced through the connection of the pin 655 received in the slot 545. The advancement of the second plate 540 advances the first clip 300 out of the distal end of the cartridge through engagement of the second prongs 524 with the distal loops of the clip 300. While the second prongs 524 actuates the movement of the clips 300, the distal loops of the clips 300 fold down and allow the distal ends to move past the first prongs 514, as described previously.

The wrist 600 may include a two pulleys 650. The second pulley 650 may control yaw rotation of the cartridge 500. The pulleys 650 may move synchronously with the one pulley 650 when the cartridge 500 is being rotated in the yaw direction. The differential movement between the pulleys 650 drives the second plate 540 forward and backward to advance the clips 300.

3. Implementing Systems and Terminology.

Implementations disclosed herein provide systems, methods and apparatus for clip appliers and associated clips to ligate tissue including an articulating wrist.

It should be noted that the terms “couple,” “coupling,” “coupled” or other variations of the word couple as used herein may indicate either an indirect connection or a direct connection. For example, if a first component is “coupled” to a second component, the first component may be either indirectly connected to the second component via another component or directly connected to the second component.

The functions for controlling the articulating medical instruments described herein may be stored as one or more instructions on a processor-readable or computer-readable medium. The term “computer-readable medium” refers to any available medium that can be accessed by a computer or processor. By way of example, and not limitation, such a medium may comprise random access memory (RAM), read-only memory (ROM), electrically erasable programmable read-only memory (EEPROM), flash memory, compact disc read-only memory (CD-ROM) or other optical disk storage, magnetic disk storage or other magnetic storage devices, or any other medium that can be used to store desired program code in the form of instructions or data structures and that can be accessed by a computer. It should be noted that a computer-readable medium may be tangible and non-transitory. As used herein, the term “code” may refer to software, instructions, code or data that is/are executable by a computing device or processor.

The methods disclosed herein comprise one or more steps or actions for achieving the described method. The method steps and/or actions may be interchanged with one another without departing from the scope of the claims. In other words, unless a specific order of steps or actions is required for proper operation of the method that is being described, the order and/or use of specific steps and/or actions may be modified without departing from the scope of the claims.

As used herein, the term “plurality” denotes two or more. For example, a plurality of components indicates two or more components. The term “determining” encompasses a wide variety of actions and, therefore, “determining” can include calculating, computing, processing, deriving, investigating, looking up (e.g., looking up in a table, a database or another data structure), ascertaining and the like. Also, “determining” can include receiving (e.g., receiving information), accessing (e.g., accessing data in a memory) and the like. Also, “determining” can include resolving, selecting, choosing, establishing and the like.

The phrase “based on” does not mean “based only on,” unless expressly specified otherwise. In other words, the phrase “based on” describes both “based only on” and “based at least on.”

The previous description of the disclosed implementations is provided to enable any person skilled in the art to make or use the present invention. Various modifications to these implementations will be readily apparent to those skilled in the art, and the generic principles defined herein may be applied to other implementations without departing from the scope of the invention. For example, it will be appreciated that one of ordinary skill in the art will be able to employ a number corresponding alternative and equivalent structural details, such as equivalent ways of fastening, mounting, coupling, or engaging tool components, equivalent mechanisms for producing particular actuation motions, and equivalent mechanisms for delivering electrical energy. Thus, the present invention is not intended to be limited to the implementations shown herein but is to be accorded the widest scope consistent with the principles and novel features disclosed herein. 

What is claimed is:
 1. A surgical instrument for securing tissue comprising: a cartridge; and one or more clips arranged within the cartridge in a nested relationship, each clip comprising: a first arm including a first distal portion that curves to form a first loop; and a second arm including a second distal portion that curves to form a second loop, wherein each clip is transitionable between an open position and a closed position, and wherein the first loop is received within the second loop when in the closed position.
 2. The surgical instrument of claim 1, wherein the first arm comprises a single strut and the second arm comprises a pair of struts, the single strut of the first arm capable of moving between the pair of struts of the second arm.
 3. The surgical instrument of claim 2, wherein the single strut comprises a first strut and the pair of struts comprise second and third struts, and wherein the first strut is received between a second strut and a third strut when the clip is in the closed position.
 4. The surgical instrument of claim 1, wherein the second loop is larger than the first loop.
 5. The surgical instrument of claim 4, wherein the first loop extends through the second loop when the clip is in the closed position.
 6. The surgical instrument of claim 1, wherein the first and second arms of each clip extend from a torsion spring comprising one or more loops.
 7. A surgical clip configured to close on tissue, comprising: a first arm comprising a first strut that curves to form a first loop; and a second arm comprising second and third struts that curve and meet to form a second loop; wherein the second loop is larger than the first loop and extends through the second loop when the clip is in a closed position, and wherein a proximal end of the first arm and a proximal end of the second arm are joined to form a vertex forming a torsion spring.
 8. The surgical clip of claim 7, wherein the first strut is received between the second and third struts when the surgical clip is in a closed position.
 9. The surgical clip of claim 7, wherein the torsion spring comprises one or more loops.
 10. A robotically controlled surgical instrument, comprising: an elongate shaft; a wrist arranged at a distal end of the elongate shaft and providing at least one degree of freedom of movement; an end effector extending from the wrist and moveable with the wrist, the end effector comprising a cartridge for delivering a plurality of clips in succession without reloading; and a plurality of clips arranged in a nested relationship within the cartridge to be delivered in succession without reloading, each clip comprising: a first arm including a first distal portion that curves to form a first loop; a second arm including a second distal portion that curves to form a second loop; and a torsion spring coupling proximal ends of the first and second arms and biasing the first and second arms toward each other to a closed position, wherein the first loop is received within the second loop when in the closed position.
 11. The surgical instrument of claim 10, wherein the plurality of clips comprises at least four clips.
 12. The surgical instrument of claim 10, wherein a length of the plurality of clips is at least 50% less than if the plurality of clips were each laid end to end.
 13. The surgical instrument of claim 10, wherein first open ends of the plurality of clips are positioned within a first track.
 14. The surgical instrument of claim 10, wherein the first and second arms of each of the plurality of clips are connected together at their respective proximal ends.
 15. The surgical instrument of claim 14, wherein the first and second arms connect together at their respective proximal ends by a loop.
 16. The surgical instrument of claim 1, wherein the first loop extends from the first arm at an angle offset from the first arm, and the second loop extends from the second arm at an angle offset from the second arm, and wherein the first and second loops form an acute angle when the clip is in the closed position.
 17. The surgical clip of claim 7, wherein the first loop extends from the first arm at an angle offset from the first arm, and the second loop extends from the second arm at an angle offset from the second arm, and wherein the first and second loops form an acute angle when the clip is in the closed position.
 18. The surgical clip of claim 7, wherein a center plane of the surgical clip bisects the surgical clip from a center of the vertex.
 19. The surgical clip of claim 18, wherein the first arm and the second arm are equally angled from the center plane when the clip is in the open position.
 20. The surgical instrument of claim 10, wherein the first loop extends from the first arm at an angle offset from the first arm, and the second loop extends from the second arm at an angle offset from the second arm, and wherein the first and second loops form an acute angle when the clip is in the closed position. 